Voter ID Address Change Form - Michigan

See Instructions Below
A. / / / /
Michigan Driver License Number or State I.D. Number
/ / ( )
Birth Date License/ID Expiration Date Daytime Telephone Number
First Name Middle Name Last Name
Residence Address
(Must be included): (Check here if this is a new address.)
Street and number, or R.R. and Box Number
, MI
City Zip County
Mailing Address (if different): (Check here if this is a new mailing address.)
Street and number, P.O Box, or R.R. and Box Number
, MI
City Zip
(Check here to remove current mailing address on file.)
I request that my address be changed.
X / /
Signature of Applicant* Today's Date
* Forms without a signature will not be processed.
B. TO REGISTER TO VOTE YOU MUST BE: A United States citizen; at least 18
years of age (by election day); and a resident of Michigan and the city or township
where you are applying to register to vote.
Are you a citizen of the United States of America? YES NO
Will you be 18 years of age on or before election day? YES NO
If you checked “NO” in response to either of these questions, do NOT complete Part C
or Part D as you cannot register to vote.
Male Female / /
Birth Date County of Residence
City Township of
City or Township of Residence
D. (Sign at both X’s)
X / /
Signature of Applicant** Today's Date
VOTER DECLARATION: I certify that:
I am a citizen of the United States.
I am a resident of the State of Michigan and will be at least a 30-day resident of
my city or township by election day.
I will be at least 18 years of age by election day.
I authorize cancellation of any previous registration.
The information that I have provided is true to the best of my knowledge under
penalty of perjury. If I have provided false information, I may be subject to a fine
or imprisonment or both under federal or state laws.
Signature of Applicant**
** Voter registrations without signatures will not be processed.
Complete only Part A if:
You need to change your residence and/or mailing address on your driver license or ID card, but are not eligible to vote (non-US
citizen or will not be 18 by election day).
You are changing your driver license or ID residence address and/or mailing address and do not want to register to vote.
Complete the entire form if:
You are a registered voter and are changing your driver license or ID card residence and/or mailing address.
You are changing your driver license or ID card residence and/or mailing address and want to register to vote for the first time.
Your residence and/or mailing address has not changed but you want to register to vote.
Notice: Michigan law requires that the same address be used for voter registration and driver license purposes. Therefore, if the
residence address you provide in the application differs from your voter registration address as it appears on the Qualified Voter
File, the Secretary of State will automatically change your registration to match the residence address on this application, after
which your voter registration at your former address will no longer be valid for voting purposes. A new voter identification card, containing
the information of your polling place, will be provided to you by the clerk of the jurisdiction where your residence is located.
If you do not wish to register to vote at this time and decline to fill out the voter registration portion of this form, your decision will remain
confidential and will only be used for voter registration purposes.
After completing the form, return it by mail to: Michigan Department of State
PO Box 30764
Lansing, MI 48909-8264
If changing your driver license or ID card address, an address label for the back of your license or ID card will be mailed to you
within 14 days. If registering to vote, your voter registration will not be valid until accepted by your local clerk. If your voter
identification card does not arrive within 3 weeks, contact your city or township clerk.
When changing your address by mail, a letter verifying the change and containing the new address will be mailed to your old address. If
you do not want residents at your old address to have your new address, then you should change your address in person at a Secretary of
State office.
ED-109W (01/13)
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